Provider Demographics
NPI:1124019583
Name:CICCHINO, ROBERT EDWARD JR (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWARD
Last Name:CICCHINO
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 WALNUT AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:WAYNESBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15370-1668
Mailing Address - Country:US
Mailing Address - Phone:724-627-5474
Mailing Address - Fax:
Practice Address - Street 1:112 WALNUT AVE
Practice Address - Street 2:SUITE A
Practice Address - City:WAYNESBURG
Practice Address - State:PA
Practice Address - Zip Code:15370-1668
Practice Address - Country:US
Practice Address - Phone:724-627-5474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008378L174400000X
WV2222208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2723459Medicaid
MD412243700Medicaid
WV3810008262Medicaid
PA0016433640004Medicaid
OH2723459Medicaid
PA0016433640004Medicaid
MD412243700Medicaid